Ensuring that 837 EDI transactions meet validity checks is critical to improving auto-adjudication and encounter submission acceptance rates. SNIP Type 3 describes the rules for balancing header and detail levels of the Claim, Premium Payment and Remittance Advice transaction sets. Previously, our blog covered the logic required to balance 835 transactions. Now we’ll look at the steps necessary to balance claims with service lines, including Coordination of Benefits loops in multiple payer scenarios.
Claims and encounters may be represented by a variety of X12 transaction types: 837 Professional, Institutional and Dental, as well as their corresponding post-adjudicated variants (298, 299, 300), intended for submission to All-Payer Claims Databases. The following logic applies to all versions of the 837 equally, with a few caveats noted below.
Rule 1 – Balancing Claim Charge Amounts
The first claim balancing rule is straightforward: given the parent-child relationship of 2300 claim loops to their 2400 service…
An EDI software’s ability to identify and respond to invalid X12 HIPAA EDI transactions is a major contributor to the effectiveness of EDI dependent organizations. Many healthcare companies appoint a business unit as stewards of the tens of thousands of transactions that are transmitted between payers, providers, and trading partners providing auxiliary services. These business units are often hard-pressed to respond to the quantity of incorrect claims, enrollments and payments received within their current EDI solutions or products.
The T-Connect EDI Management Suite is Tallan’s healthcare EDI product, providing actionable insight, alerting, and painless mechanisms to respond to invalid X12 EDI transactions flowing in and out of the organization. The following is a brief introduction into some of these capabilities.
The EDI solution consists of several components working in unison to introduce, augment or replace an EDI processing system.
· The T-Connect Management Portal,…
835 and 837 EDI transactions have transformed the adjudication cycle for providers and health plans over the last two decades, but challenges remain in reconciling payments with claims. Recently, we’ve broken down the requirements for SNIP 3 claim balancing. Today we’ll focus on the 835 Claim Payment/Remittance Advice. Health plans submit 835s to providers (or their intermediaries) to explain which claims are being paid, and any reductions to the submitted amount and the reasoning for the adjustment. This is an important function – a significant pain point experienced by providers is the reconciliation of their income against claims submitted.
Before this valuable information can be loaded in practice management software, the 835 should pass validation checks. Common issues affecting 835s are balancing errors between the header and detail payment amounts. Imbalanced 835s lower the quality of reporting and can lead to billing…